京都大学 / 新制・課程博士 / 博士(医学) / 甲第25155号 / 医博第5041号 / 新制||医||1070(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 今中 雄一, 教授 山本 洋介, 教授 永井 洋士 / 学位規則第4条第1項該当 / Doctor of Agricultural Science / Kyoto University / DGAM

Orientador: José Vicente Tagliarini / Resumo: Introdução: a doença degenerativa da coluna cervical é prevalente e incapacitante, levando a dor e sintomas neurológicos. A cirurgia de discectomia e fusão por via anterior é bem estabelecida para o seu tratamento, sendo realizada com a colocação de dispositivos interssomáticos (cages) e placas anteriores. Novos cages ancorados prometem diminuir a disfagia pós-operatória deste procedimento. Objetivo: verificar por meio de uma revisão sistemática a efetividade da utilização de cages ancorados na redução de disfagia pós-operatória sem prejuízo dos outros benefícios obtidos com a cirurgia. Métodos: foram pesquisadas as bases de dados Embase, MEDLINE, LILACS, Scopus, Web of Science e Cochrane CENTRAL. Foram reunidos estudos observacionais e experimentais que avaliaram a utilização de cages com placas anteriores e cages ancorados em pacientes com doença degenerativa da coluna cervical. Os desfechos avaliados foram disfagia, aumento do escore JOA, diminuição do escore NDI, fusão pós-operatória, aumento da lordose cervical, tempo de cirurgia, perda intraoperatória de sangue e resultados bons/excelentes pelos critérios de Odom. Para metanálise foi empregado o software RevMan 5.3 fornecido pela Colaboraçao Cochrane. Resultados: o número total de pacientes em 30 estudos selecionados foi de 2178, sendo 1089 em cada grupo. Em 48 horas, 30 dias, 90 dias e 12 meses após a cirurgia, houve menores índices de disfagia no grupo dos cages ancorados, chegando a RR 0,15 (IC95% 0,08-0,27, I2=0%) n... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: cervical degenerative disc disease is a highly prevalent and disabling disease, leading to pain and neurologic symptoms as weakness and radiculopathy. Anterior cervical diskectomy and fusion (ACDF) is a well stabilished procedure for its treatment, usually performed by placing a spacer (cage) with the addition of an anterior fixation plate. New anchored spacers have been introduced with the promise of a faster less morbid procedure. Study goals: to perform a systematic review for the analysis of postoperative dysphagia between standard and anchored anterior cervical spacers, also taking into consideration quality-of-life and radiologic parameters. Methods: a comprehensive search was performed in the MEDLINE, Scopus, Web of Science, LILACS and Cochrane CENTRAL databases. Observational and interventional studies evaluating outcomes after ACDF with conventional cage-plate construct and anchored spacers were selected. The following outcomes were evaluated: dysphagia, JOA/mJOA score, NDI score, fusion rates, cervical lordosis improvement, operative time, intraoperative blood loss and rate of good/excellent outcomes by Odom’s criteria. The RevMan software (v5.3) was used to perform meta-analysis. Results: a total of 2178 patients were enrolled in 30 studies, with 1079 patients in both control and intervention groups. At all postoperative moments (48 hours, 30 days, 90 days and 12 months), there was a significantly lower rate of dysphagia in the anchored spacer group, ... (Complete abstract click electronic access below) / Mestre

A dor lombar acomete a humanidade desde tempos remotos, tendo seus primeiros relatos descritos no \"Papiro de Edwin Smith\" (1500 a.C.). Acredita-se que durante a vida até 90% da população terá pelo menos um episódio de dor lombar, sendo tal patologia uma das principais causas de afastamento do trabalho, acarretando em vultosos prejuízos financeiros anuais. Cinco a 10% dos pacientes que possuem lombalgia também apresentam dor irradiada para o membro inferior (ciatalgia) e esta última, 85% das vezes é secundária à hérnia de disco lombar (HDL), cuja prevalência anual na população geral é estimada em 2.2%. O objetivo deste estudo foi avaliar a eficácia da aplicação do laser diodo de 980 nm intradiscal no tratamento da ciatalgia em pacientes portadores de hérnias lombares contidas em comparação com o grupo controle. Vinte e cinco pacientes (30 discos intervertebrais) com HDL e dor neuropática de distribuição metamérica foram randomizados, 12 no grupo controle e treze no grupo laser. No grupo controle foi feita injeção de dexametasona, clonidina e lidocaína intradiscais e no grupo laser aplicada média de 900 J de energia intradiscal, além das mesmas medicações. Os grupos foram avaliados nos tempos antes, imediatamente após, um mês, dois, três, seis e 12 meses decorridos do procedimento quanto aos parâmetros: dor, pela Escala Numérico Visual (ENV), uso de medicações para o controle desse sintoma e efeitos colaterais. Os resultados demonstraram queda nas médias das ENVs e necessidade de medicações para controle da dor em ambos os grupos logo após o tratamento (p<0,05), que perdurou no grupo laser onde houve média de redução de 80,73% nas ENVs, e de 75,51% na necessidade de medicação em um ano de seguimento (p<0,05). Já no grupo controle, as ENVs e as necessidades de analgésicos voltaram a ser semelhantes aos valores anteriores ao tratamento a partir do segundo mês de avaliação (p>0,05). Foi verificada predominância da doença no sexo masculino (68%), com faixa etária média de 44 anos, e baixa incidência de efeitos colaterais semelhantemente a dados anteriormente relatados. O laser diodo de 980 nm é eficaz na redução da ciatalgia secundária à herniação discal contida e superior à injeção intradiscal de clonidina, dexametasona e lidocaína, no que se refere à duração da redução das ENVs e da necessidade de medicações analgésicas. / Lumbar pain affects mankind from earliest times having its first descriptions in the \"Edwin Smith Papyrus\" (1500 BC). It is believed that during life up to 90% of the population will have at least one episode of low back pain, being such pathology one of the main causes of work withdrawal with huge annual financial losses. Five to 10% of patients with low back pain also have lower-limb pain (sciatica), and the latter, 85% of the time, is secondary to lumbar disc herniation (LDH), whose annual prevalence in the general population is estimated at 2.2%. The objective of this study was to evaluate the efficacy of intradiscal diode laser 980 nm wavelength in comparison with a control group on sciatica treatment in patients with contained lumbar disc herniations. A total of 25 patients (30 intervertebral discs) with LDH and neuropathic pain of metameric distribution were randomized, 12 patients in the control group and 13 patients in the laser group. In the control group, intradiscal injection of dexamethasone, clonidine and lidocaine was performed and in the laser group an average of 900 J of intradiscal energy was delivered, in addition to the same medications. The groups were evaluated at the time before, immediately after, 1, 2, 3, 6, and 12 months after the procedure for the parameters: pain measured by Visual Numerical Scale (VNS), medication use to control this symptom and side effects. The results showed a decrease in VNS and the need for pain control medications in both groups after treatment (p<0.05) that lasted in the laser group which demonstrated an average in VNSs reduction of 80,73% and in pain analgesic needs of 75,51% after 1 year (p<0,05). In the control group, VNSs and analgesic needs were again similar to pre-treatment values from the second month of evaluation (p>0.05). The predominance of the disease was found in males (68%), with a mean age of 44 years and a low incidence of side effects similar to the data reported before. The 980 nm diode laser is effective in reducing sciatica due to contained LDH and superior to intradiscal injection of clonidine, dexamethasone and lidocaine for the duration of the reduction of VNS and need for analgesic medications.

<div>In this thesis, the design of the robotic cannula for minimally invasive robotic lumbar discectomy is presented. Lumbar discectomy is the surgery to remove the herniated disc material that is pressing on a nerve root or spinal cord. </div><div><br></div><div>Recently, a robotic approach to performing this procedure has been proposed that utilizes multiple teleoperated articulated instruments inserted into the surgical workspace using a single cannula. In this paper, a new robotic cannula system to work in conjunction with this new procedure is presented. It allows for the independent teleoperated control of the axial position and rotation of up to three surgical instruments at the same time. The mechanical design, modeling, controller design, and the performance of the prototype of the new system are presented in this paper demonstrating a fully functioning device for this application. A novel worm gear and rack system allow for the instrument translation while and embedded gear trains produce the rotational movement. Steady-state errors of less than 10 microns for translation and less than 0.5 degree for rotation motion are achieved in position tracking; steady-state errors of less than 100 micron per second of translation and less than 0.5 degree per second for rotation motion are obtained in speed tracking. </div>

<p>In a prospective randomised double-blind study eighty patients with MRI verified lumbar disc herniation and corresponding clinical findings underwent microscopic disc removal. The patients were peroperatively given systemic and local corticosteroids or placebo, and followed for 2 years. The hospital stay and time to return to full-time work was significantly shorter in the treatment group. Pain measured as worst pain during the last week was also lower in the corticosteroid group. The results indicate that peroperative treatment with corticosteroids reduces pain and improves the functional outcome in patients operated for lumbar disc herniations.</p><p>To evaluate whether thermal quantitative sensory testing (QST) is applicable in the study of sensory dysfunction in lumbar disc herniations 66 patients with disc herniations underwent thermal QST. We found that thermal QST reflects sensory dysfunction in patients with lumbar disc herniations. However, thermal QST seems to have a poor predictive value for identifying the anatomic location of a herniated lumbar disc.</p><p>Quantitative sensory testing (QST) was used to detect damage to the myelinated A-delta fibres (cold sense) and the unmyelinated C-fibres (warmth sense). Corticosteroids combined with surgery in lumbar disc surgery improved the normalisation for the warmth disturbance compared to the control group. </p><p>A prospective analysis was performed on the predictive value of preoperatively determined lumbar lordosis and flexion for pain and disability in patients treated by microscopic lumbar disc surgery. Preoperative hyperlordosis correlated to more pain postoperatively (p=0.004). In patients with hypoflexion there was an association between hyperlordosis and moderate or severe pain postoperatively (p<0.001). The same outcomes were found for DRI. The stiff and straight back indicates a good outcome of lumbar disc surgery concerning pain and disability. </p>

In a prospective randomised double-blind study eighty patients with MRI verified lumbar disc herniation and corresponding clinical findings underwent microscopic disc removal. The patients were peroperatively given systemic and local corticosteroids or placebo, and followed for 2 years. The hospital stay and time to return to full-time work was significantly shorter in the treatment group. Pain measured as worst pain during the last week was also lower in the corticosteroid group. The results indicate that peroperative treatment with corticosteroids reduces pain and improves the functional outcome in patients operated for lumbar disc herniations. To evaluate whether thermal quantitative sensory testing (QST) is applicable in the study of sensory dysfunction in lumbar disc herniations 66 patients with disc herniations underwent thermal QST. We found that thermal QST reflects sensory dysfunction in patients with lumbar disc herniations. However, thermal QST seems to have a poor predictive value for identifying the anatomic location of a herniated lumbar disc. Quantitative sensory testing (QST) was used to detect damage to the myelinated A-delta fibres (cold sense) and the unmyelinated C-fibres (warmth sense). Corticosteroids combined with surgery in lumbar disc surgery improved the normalisation for the warmth disturbance compared to the control group. A prospective analysis was performed on the predictive value of preoperatively determined lumbar lordosis and flexion for pain and disability in patients treated by microscopic lumbar disc surgery. Preoperative hyperlordosis correlated to more pain postoperatively (p=0.004). In patients with hypoflexion there was an association between hyperlordosis and moderate or severe pain postoperatively (p&lt;0.001). The same outcomes were found for DRI. The stiff and straight back indicates a good outcome of lumbar disc surgery concerning pain and disability.